Most common arthritis with increasing prevalence due to aging and obesity!
◦ Primary: Idiopathic. Usually affects hands, knees, hips, spine. Also MTP great toe. ◦ Secondary: Due to trauma, infection, congenital, systemic diseases
Pathophysiology: Mechanical AND biochemical. As get older, disruption in cartilage remodeling process = Damage to articular cartilage → joint space narrows → subchondral cysts and osteophytes form.
Pain worse with activity/weight bearing, better with rest
Morning stiffness is short ( <30 min)
Enlarged joints that are tender (DIP = Herberden's nodules, PIP = Bouchard's nodules, knees, hip, spine)
Crepitus
Limited ROM
Diagnosis (according to American College of Rheumatology)
Knee – clinical dx
Hip – clinical and XR dx (89% sensitive/91% specific)
Hand – clinical (94% sensitive/87% specific)
Clinical: · >50 yo
short AM stiffness (<30 min)
crepitus
bone tenderness
osseous enlargement
no palpable warmth
Clinical: · Pain in hip AND 2 of: · XR: osteophytes, joint space narroriwng · Normal ESR
Clinical: Pain/stiff/ache of hand + 3 of: hard tissue enlargement of at least 2/10 “selected” joints hard tissue enlargement of at last 2/10 DIPs <3 swollen MCP joints deformity of at least 1/10 “selected” joints
XR: joint space narrowing, osteophytes, bony sclerosis, cyst formation, joint space collapse
Strongest sign = worse hip pain with internal or external hip rotation (w/ knee fully extended) (Grade A rec)
Shoulder, Elbow, Ankle: Usually history of injury or other joints with OA. Need radiograph for diagnosis.
Treatment: Goal is pain control and improve functioning
Non-pharmacologic:
◦ Self-Management and patient education ◦ Weight loss (slow)/maintaining optimal weight ◦ Regular exercise ▪ Low impact aerobic:** walking, swimming, bike, water aerobics (decreases pain and improves function for knee OA) ◦ Physical Therapy: ROM, strengthening, heat/therapeutic ultrasound, TENS ◦ Braces, orthotics (evidence for wedged insoles for various knee deformity), walking aids ◦ Proper footwear (hip, knee OA): flat/low heel, flexible shoe (rather than stiff) ◦ patellar taping ◦ acupuncture
Pharmacologic:
◦ Acetaminophen (up to 4 gm/day) - 1st line ◦ NSAIDS – use if inadequate response to Acetaminophen. Ibprofen 200-800 mg TID-QID or Naproxen 200-500 mg BID. Start low, titrate up. ◦ Topical NSAID – Voltaren (Diclofenac) 1% gel, approved for OA knee and hands. 4 gm QID max in LE; 2gm QID max in UE. ◦ Topical Capsaicin: Use as adjunct, and OTC. TID-QID. ◦ Tramadol (u-opioid agonist) 50 q6 prn ◦ Opiates – use sparingly, not strong evidence for benefit ◦ Joint injections ▪ Corticosteroids: only shown beneficial for knee, hip, hand (typically provide short term pain relief (2-4 weeks)). No more than 4 injections/year. ▪ Hyaluronic acid: Endogenous = lubricates, hydrates, provides elasticity to joint. Exogenous = viscosupplementation. Pros: Benefit in knee OA, use in those with C/I to NSAIDs, few adverse events. Cons: 3-5 weekly injections, duration of benefit shorter ◦ Glucosamine (500 mg TID)/Chondroitin (200-400 mg TID): ▪ GAIT trial (large 1580 person NIH trial) showed no benefit compared to placebo, including 2 year out data showed no difference in pain compared with placebo. BUT is relatively safe, except do not take if have shellfish allergy. Trial for 60 days. ◦ Plaquenil for inflammatory OA
Surgical:
◦ Referral indications: ▪ Failure of conservative therapy, with continued substantial impact on quality of life ▪ To remove loose pieces bone/cartilage causing buckling or locking ◦ Types: ▪ Arthoscopy plus I &D – debridement of torn meniscus, ligaments, cartilage fragments; controversial. Controlled trial 2002 NEJM (Moseley et al) showed no better than placebo in 180 patients ▪ Total joint replacement – most evidence for knee and hip. NIH data show 90% improvement pain/function by more than 20 years of follow-up data · DVT prophylaxis needed · PT post operatively at least 4-6 week; improvement plateaus around 12-26 weeks figure 1 Sources: Weinstock, M et al. “Osteoarthritis.” Resident's Guide to Ambulatory Care, 6th ed. , 2009.
“Osteoarthritis” CME Resource, October 2010, Vol. 136, No. 2.
Felson DT. Osteoarthritis of the knee. NEJM 2006; 354: 841-8. Patient Education: AAFP “How to Stay Active” http://www.aafp.org/afp/2004/0301/p1211.html Patellar taping instructions: http://www.physioadvisor.com.au/11343550/patella-taping-mcconnell-taping-physioadvisor.htm AAFP “Glucosamine” http://www.aafp.org/afp/2008/0815/p481.html
- Most common arthritis with increasing prevalence due to aging and obesity!
◦ Primary: Idiopathic. Usually affects hands, knees, hips, spine. Also MTP great toe.◦ Secondary: Due to trauma, infection, congenital, systemic diseases
Risk Factors
Symptoms and Signs (General for all joints)
Diagnosis (according to American College of Rheumatology)
(89% sensitive/91% specific)
(94% sensitive/87% specific)
· >50 yo
· Pain in hip
AND
2 of:
· XR: osteophytes, joint space narroriwng
· Normal ESR
Pain/stiff/ache of hand + 3 of:
hard tissue enlargement of at least 2/10 “selected” joints
hard tissue enlargement of at last 2/10 DIPs
<3 swollen MCP joints
deformity of at least 1/10 “selected” joints
Treatment: Goal is pain control and improve functioning
- Non-pharmacologic:
◦ Self-Management and patient education◦ Weight loss (slow)/maintaining optimal weight
◦ Regular exercise
▪ Low impact aerobic:** walking, swimming, bike, water aerobics (decreases pain and improves function for knee OA)
◦ Physical Therapy: ROM, strengthening, heat/therapeutic ultrasound, TENS
◦ Braces, orthotics (evidence for wedged insoles for various knee deformity), walking aids
◦ Proper footwear (hip, knee OA): flat/low heel, flexible shoe (rather than stiff)
◦ patellar taping
◦ acupuncture
- Pharmacologic:
◦ Acetaminophen (up to 4 gm/day) - 1st line◦ NSAIDS – use if inadequate response to Acetaminophen. Ibprofen 200-800 mg TID-QID or Naproxen 200-500 mg BID. Start low, titrate up.
◦ Topical NSAID – Voltaren (Diclofenac) 1% gel, approved for OA knee and hands. 4 gm QID max in LE; 2gm QID max in UE.
◦ Topical Capsaicin: Use as adjunct, and OTC. TID-QID.
◦ Tramadol (u-opioid agonist) 50 q6 prn
◦ Opiates – use sparingly, not strong evidence for benefit
◦ Joint injections
▪ Corticosteroids: only shown beneficial for knee, hip, hand (typically provide short term pain relief (2-4 weeks)). No more than 4 injections/year.
▪ Hyaluronic acid: Endogenous = lubricates, hydrates, provides elasticity to joint. Exogenous = viscosupplementation. Pros: Benefit in knee OA, use in those with C/I to NSAIDs, few adverse events. Cons: 3-5 weekly injections, duration of benefit shorter
◦ Glucosamine (500 mg TID)/Chondroitin (200-400 mg TID):
▪ GAIT trial (large 1580 person NIH trial) showed no benefit compared to placebo, including 2 year out data showed no difference in pain compared with placebo. BUT is relatively safe, except do not take if have shellfish allergy. Trial for 60 days.
◦ Plaquenil for inflammatory OA
- Surgical:
◦ Referral indications:▪ Failure of conservative therapy, with continued substantial impact on quality of life
▪ To remove loose pieces bone/cartilage causing buckling or locking
◦ Types:
▪ Arthoscopy plus I &D – debridement of torn meniscus, ligaments, cartilage fragments; controversial. Controlled trial 2002 NEJM (Moseley et al) showed no better than placebo in 180 patients
▪ Total joint replacement – most evidence for knee and hip. NIH data show 90% improvement pain/function by more than 20 years of follow-up data
· DVT prophylaxis needed
· PT post operatively at least 4-6 week; improvement plateaus around 12-26 weeks
figure 1
Sources:
Weinstock, M et al. “Osteoarthritis.” Resident's Guide to Ambulatory Care, 6th ed. , 2009.
“Osteoarthritis” CME Resource, October 2010, Vol. 136, No. 2.
Felson DT. Osteoarthritis of the knee. NEJM 2006; 354: 841-8.
Patient Education:
AAFP “How to Stay Active” http://www.aafp.org/afp/2004/0301/p1211.html
Patellar taping instructions: http://www.physioadvisor.com.au/11343550/patella-taping-mcconnell-taping-physioadvisor.htm
AAFP “Glucosamine” http://www.aafp.org/afp/2008/0815/p481.html